Project ECHO®

Ellen Baker, MD, MPHUT MD Anderson Cancer Center

Extension for Community Healthcare Outcomes

No financial relationships to disclose

“In the U.S. and around the world, people are not getting access to the specialty care they need, when they need it, for complex and treatable conditions”

-Sanjeev Arora

• 121,356 mi2

• Population - 2.08 million

• Estimated > 28,000 infected with HCV

• In 2004 less than 5% had been treated

• 2,300 prisoners were HCV positive (~40% of those entering the corrections system), none were treated

• No primary care physicians treating HCV as of 2004*

Hepatitis C in New Mexico

• In response to Hepatitis C crisis in New Mexico Dr. Arora developed Project ECHO

• Patients in rural areas unable to travel to University clinics

• Community providers not comfortable treating HCV

• Identified primary care providers from 16 rural clinics and 5 prisons in New Mexico

Started a telementoring program

Project ECHOExtension for Community Healthcare Outcomes

*Goal to demonopolize knowledge

• Conduct regular teleECHO™ videoconferences with multidisciplinary team at UNM and providers in partnering clinics in rural areas

• Through regularly scheduled videoconferences, train physicians, physician assistants, nurse practitioners, nurses, pharmacists in under-resourced regions, in best practice HCV treatment

• Initiate case-based guided practice

• Collect data and monitor outcomes, assess cost and effectiveness of programs

Steps

• Prospective study of 407 patients with HCV

• Compared patients treated at the University with patients treated at 21 rural clinics/prisons

• No difference in Hepatitis C cure rates (SVR) between the two groups

• No significant differences in serious adverse events between UNM and rural clinics

• Improved patient satisfaction and physician and provider self-efficacy

Project ECHO – Hepatitis C

Arora, et al., NEJM, 364(23); 2011

Telemedicine vs. Telementoring

TelemedicineProvider to Patient Communication

Telehealth/mentoringProvider to Provider

Mentoring

• Demonopolize knowledge- Share knowledge between specialists at academic medical centers and providers in low resource regions that lack specialty care.

• Capacity Building - Develop local capacity to safely and effectively treat complex conditions in regions without specialty expertise by connecting specialists with local providers.

• Reduce disparities - Develop a model to treat complex diseases in rural and underserved locations.

Goals of Project ECHO

• Use Technology to leverage scarce resources

• Share “best practices” to reduce disparities

• Case based learning to master complexity

• Monitor outcomes

MethodsThe Four Pillars of ECHO

Arora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.

• Weekly/monthly/regular videoconferences

• Community providers present cases (hx/pex, lab, treatment, challenges)

• Feedback and guidance provided by the specialists

• Community providers and specialists work together to provide quality care

• Short didactics to complement case presentations

Project ECHO Format

Telementoring not Telemedicine

Summary of benefits of Project ECHO

Expanding Project ECHO

Dr. Sanjeev AroraU. of New Mexico

Dr. Ernest HawkOVP CP&PS

Dr. Kathleen SchmelerGyn Onc

Inequity of Cervical Cancer

85% of cervical cancer cases occur in the developing world

Rio Grande Valley:

• Population of ~1.3 million

• 90% of population is Hispanic

• 40% below the poverty line

• <10% of eligible women receiving cervical cancer screening

• Limited number of providers

• Cervical cancer rates are 30% higher compared with non-border counties in Texas

Texas-Mexico Border

Cervical Cancer PreventionSouth Texas

• Goal: Partnerships to increase local capacity and improve access to specialty consultations in management of cervical dysplasia

• Leaders: Kathleen Schmeler, MD Anderson and University of Texas faculty in gynecology and gynecologic oncology

• Local Partners: FQHCs along the Texas-Mexico border, and other clinics in underserved regions

• International Partners: Brazil, El Salvador, Mexico

• Goal: Partnerships with local mental health clinics in Texas to provide tobacco treatment services for patients with mental illness. Now opened to other providers

Tobacco Treatment

• Goal: Partnerships with Family Medicine Residency Programs to teach cancer survivorship to residents

• Goal: Train community health workers to provide support for cancer survivors, teaching and encouraging physical activity and good diet.

Cancer Survivorship in Texas

• Goal: Partnerships to improve delivery of palliative care services in Africa

• Leaders: MD Anderson palliative care team

• Partners in: Kenya, Nigeria, Ghana, Zambia, South Africa, Brazil

Palliative Care - Africa

• Goal: Partnerships to increase diagnostic accuracy and provider self-efficacy through clinical skill development using dermoscopy.

• Leaders: MD Anderson dermatology team

• Partners: 7 dermatology residency programs in Texas and Missouri

Early Melanoma Diagnosis

• Goal: Partnership with Maputo Central Hospital and MOH, Mozambique for cancer management.

• Brazil Partners: Hospital Israelita Albert Einstein, Hospital de Cancer de Barretos, A.C. Camargo Cancer Center

• Mozambique Partners: Hospital Central de Maputo, Mavalane Hospital

• Clinics: Multidisciplinary clinics conducted in Portuguese, once a month. Training and exchange of personnel.

• Research: Cervical cancer screening using primary HPV testing

Mozambique: Cervical, Breast, Head &Neck and Hematologic Cancers

• Goal: Partnerships to provide guidance in the management of gynecologic cancers.

• ECHO serves as a foundation to increase communication and promote collaboration among the partners.

• Leaders: MD Anderson and Universidad de la Republica- Montevideo

• Partners: Physicians in Bolivia, Guatemala, Chile, Colombia, Ecuador, El Salvador, Paraguay, Peru, Uruguay, Mexico, Argentina

• Clinics: Multidisciplinary clinics conducted monthly in Spanish, since September, 2015

Management of Gynecologic Cancers in Latin America

• ECHO is part of a larger, comprehensive program that includes trainee exchanges, country visits, and a structured curriculum

• 5 Pilot sites identified: Vietnam, Kenya, Ethiopia, Mozambique, The Caribbean

• Other IGCS programs using ECHO in Belarus, Kazakhstan

IGCS Gynecologic Oncology Fellowship Program

DaNang Oncology Hospital

Hospital Central de Maputo

Moi University, Kenya

• Provider capacity building including hands-on training

• Development of affordable technologies for cancer prevention, diagnosis and treatment

• Health system strengthening through partnerships

ECHO is Part of a Larger Strategy

• Hands-on Training:

• Surgical/medical onc

• Technical courses

• LEEP and colposcopy

• Trainee Exchanges:

• For example: Brazil and Mozambique

• IGCS Global Curriculum:

• 2-year training program in Gynecologic Oncology

• Twinning approach

• Five pilot sites for 2017-18

• - Vietnam, Ethiopia, Kenya, Mozambique, Caribbean

Provider Capacity Building

Health System Strengthening

- National Cancer Control Planning - Education of the public and government officials- Partnering with policy makers, MOH, universities, NCI,

international organizations, NGOs

Isaura Nyusi

First Lady of Mozambique

• Partnerships and knowledge-sharing among cancer control and research professionals to support improvements in strategic cancer control including incorporation of evidence into national cancer control plans

• Focus may vary depending on country/region

• Generally includes representatives from several countries in the region

NCI- Center for Global Health

• Expanded across diseases and specialties, across rural and urban areas, to different types of delivery services

• 10 Superhubs – Centers that train other institutions to use the ECHO model. MD Anderson is a training center focused on oncology.

• ~170 hubs for more than 65 diseases in 23 countries

Project ECHO Globally

Moving Knowledge, not Patients

Thank you!

Ellen Baker, MD MPH Program Director Ebaker1@mdanderson.org

Melissa S. Lopez, MS Program ManagerMslopez1@mdanderson.org

Kathleen Schmeler, MDkschmele@mdanderson.org